WORLD GASTROENTEROLOGY NEWS World Digestive Health Day 2013: LIVER CANCER Act Today. Save Your Life Tomorrow. Editorial

Editorial

WORLD GASTROENTEROLOGY NEWS

Official e-newsletter of the World Gastroenterology Organisation www.worldgastroenterology.org

VOL. 18, ISSUE 1 APRIL 2013

World Digestive Health Day 2013: In this issue LIVER CANCER Act Today. Save Your Life Tomorrow. Awareness. Prevention. Detection. Treatment.

Douglas R. LaBrecque, MD, FACP The Future of Colorectal Cancer Professor, Internal Medicine Prevention in Developing Countries University of Iowa Healthcare René Lambert, MD Chairman, WDHD 2013 Steering Committee

The World Gastroenterology Organisa- Why liver cancer? Hepatocellular car- tion (WGO) established World Digestive cinoma (HCC, also known as primary Health Day (WDHD) in 2004. Although liver cancer) is variably estimated to be still celebrated on May 29th each year, the fifth to seventh most common cancer The Future of Colorectal Cancer 1,2 Prevention in the United States; the date on which WGO was incorpo- in the world and it continues to be the rated in 1958, WDHD has become a third most common cause of death from A perspective from a high burden, 1,2 sufficient resource country year long, global, public health, advocacy cancer (second most common in men) . Dennis J. Ahnen, MD and awareness campaign. WDHD an- In some countries, it is either the number nually focuses on a specific digestive or one (Mongolia) or number two malignant liver disorder with the goal of increasing neoplasm (China). In the United States awareness by the public, medical practi- of America, it is the fastest rising cancer tioners, government health policy makers, by incidence and death rate3. Every 30 and philanthropic groups of the need for seconds, one person in the world dies prevention, diagnosis and management from liver cancer, which is almost entirely of a specific global health problem. The preventable. The annual global death rate theme in 2013 is: LIVER CANCER: Act from HCC of just under 700,000 ap- Gallstone Disease – a Heavier Burden in Today. Save Your Life Tomorrow. Aware- proximates the annual incidence, reflect- India! ness. Prevention. Detection. Treatment. ing the limited therapeutic options as well Vinay K. Kapoor, FRCS, FACS, FACG as the late diagnosis in most cases4,5. Significant advances in diagnosis and therapy now produce a 50-70% five year survival in those diagnosed with early, minimal disease who receive the best current therapies. But such therapies are almost exclusively available in high resource countries, and even there not to all of the affected patients. Low resource countries tend to lack the broad public 2 WORLD GASTROENTEROLOGY NEWS APRIL 2013

Contents

Editorial WDHD News

World Digestive Health Day 2013: LIVER CANCER World Digestive Health Day 2013 19 Act Today. Save Your Life Tomorrow. 1 Douglas R. LaBrecque, MD, FACP WGO & WGOF News

Scientific News 5th Egyptian Hepatology and Gastroenterology Post Graduate Course; 14th Egyptian International An Introduction to Two Perspectives on Colorectal Workshop on Therapeutic Endoscopy 21 Cancer Prevention 6 Ibrahim Mostafa, MD Henry J. Binder, MD Greger Lindberg, MD WGO Membership Update 23

The Future of Colorectal Cancer Prevention in Developing Countries 7 WGO Training Centers in Africa René Lambert, MD – A New Partnership in Training 25

The Future of Colorectal Cancer Prevention in the WGO Global Guidelines United States 12 Dennis J. Ahnen, MD WGO’s New Graded Evidence System 27 Justus Krabshuis Letter to the Editors Anton Le Mair, MD

Gallstone Disease – a Heavier Burden in India! 15 Calendar of Events Vinay K. Kapoor, FRCS, FACS, FACG

WGO Calendar of Events 30 World Congress

GASTRO 2013 APDW/WCOG Shanghai News 16

VOL. 18, ISSUE 1 e-WGN Editorial Board Editor: Henry J. Binder, Greger Lindberg • Todd Baron, USA • Klaus Mergener, USA Managing editor: Leah Kopp • Jason Conway, USA • Douglas Rex, USA Art Production: Jennifer Gubbin • Rodolfo Corti, Argentina • Max Schmulson, Mexico Editorial Office:WGO Executive Secretariat, 555 East Wells • Paul Goldberg, South Africa • Nicholas Shaheen, USA Street, Suite 1100, Milwaukee, WI 53202 USA • Abdel-Meguid Kassem, Egypt • Parul Shukla, India Email: [email protected] • Rene Lambert, France • Martin Smith, South Africa • Joseph Lau, China, Hong Kong • Wendy Spearman, South Africa • Pier-Alberto Testoni, Italy • Nicholas Talley, Australia • Bader Fayaz Zuberi, Pakistan • Mamoru Watanabe, Japan • Chun-Yen Lin, Taiwan

©2013 World Gastroenterology Organisation. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form without the prior permission of the copyright owner. 3 WORLD GASTROENTEROLOGY NEWS APRIL 2013

awareness and medical infrastructure, HEPATITIS B as well as generally available state of Hepatitis B is one of the most ne- the art technology (ultrasound, CT, glected epidemics in the world. One MRI) for early diagnosis. The current in 3 people worldwide have been best surgical and medical therapies are infected with HBV and 400,000,000 of very limited availability, if avail- have chronic hepatitis B. It is sec- able at all, due to high costs, lack of ond only to tobacco in causing the adequately trained medical personnel, most cancer deaths worldwide. The and limited to no coverage by govern- hepatitis B vaccine, the FIRST true ment health plans. anti-cancer vaccine, has been avail- Unfortunately, low resource coun- able since 1982 and is more than tries are disproportionately affected 95% effective. Global efforts at HBV by HCC. More than eight out of ten vaccination of infants began in 1990, (84%) of the almost 700,000 deaths when the WHO estimated that only reported by WHO in 2008 occurred 1% of infants received the recom- in low resource countries. Over 80% mended three doses of hepatitis B of HCC occur in sub-Saharan Africa, vaccine. Although 93% of countries southeast Asia and East Asia (including had introduced the hepatitis B vaccine Mongolia)1,5. At least 80% of all HCC into their routine vaccination sched- are associated with chronic viral infec- ules by 2011 the number actually many decades. In the meantime, over tion with the hepatitis B virus (HBV) vaccinated had risen to only 75%8, 400 million individuals with chronic or hepatitis C virus (HCV). HBV which still leaves a full quarter of the hepatitis B remain at risk from the infections alone account for 75% to world’s infants uncovered and they dire complications of this devastating 80% of these cases. HCV is responsible live in areas of the world with chronic infection. Excellent therapies are now for 10% to 20% of cases6. Additional carrier rates for hepatitis B of up to available which significantly reduce risk factors, which may cause HCC or 20% and more. Coverage in the SE the risk of progression to cirrhosis, act as co-factors in producing cirrhosis Asia Region languishes at only 56%8. liver failure and HCC. However, these and HCC, include consumption of Seven percent of countries still have drugs remain generally unavailable foodstuffs contaminated by the fungal not introduced hepatitis B vaccine in major parts of the world where toxin aflatoxin B1 (AFB1), which con- into their routine childhood vaccina- identical drugs are now routinely taminates groundnuts, maize and tree tion schedules and only 52% recom- available for the treatment of HIV nuts in warm, humid environments mended that the initial dose be given infection. This obvious inequity must in sub-Saharan Africa, SE Asia and within the first 24 hours to prevent be addressed and resolved quickly China. Aflatoxin produces a specific perinatal transmission of the hepatitis before additional large numbers of in- DNA mutation in a hotspot region of B virus as per international stan- dividuals die unnecessarily. Programs the p53 cancer suppressor gene and is dards9. Thirty to forty percent of those to prevent aflatoxin contamination of synergistic with HBV in the produc- infected with chronic hepatitis B can foodstuffs have also been demonstrat- tion of HCC. Some studies suggest a be expected to die from liver failure ed to be highly successful, but remain possible synergistic role with HCV as or HCC. The benefits of national difficult to implement broadly due to well. Other risk factors include excess vaccination campaigns have been lack of education and cost. alcohol intake, diabetes/obesity/non- well documented in areas as diverse HEPATITIS C alcoholic steatohepatitis (NASH) and as Taiwan, The Gambia and Amazo- Prevention of hepatitis C infection rare metabolic disorders, including nia, Brazil, where dramatic drops in presents a somewhat more difficult tyrosinemia, hemochromatosis, alpha-1 hepatitis B carrier rates from 10% to problem because there is no effective anti-trypsin deficiency, and several 1.1%, 10% to 0.6%, and 15.3% to vaccine to prevent hepatitis C infec- prophyrias6,7. 3.7%, respectively, with subsequent tion and there is unlikely to be one The above facts are well known. The drops in the occurrence of HCC, have in the foreseeable future. Prevention two primary causes, HBV and HCV been demonstrated. must rely on education of patients infection, are both preventable and While the benefits of true universal concerning the risks of acquiring treatable and 1 in 12 of the world’s infant immunization against hepatitis HCV infection from exposure to population is currently living with B are obvious as a preventive mea- blood and bodily fluids and strict chronic hepatitis B or C. sure, they will also not be realized for 4 WORLD GASTROENTEROLOGY NEWS APRIL 2013

adherence to the principles of infec- tive therapies for hepatitis C are now tragedies whose burden of disease has tion control. The WHO estimated in available which will cure 70% or more been neglected for far too long. With- 2006 that 16 thousand million injec- of patients and even better treatments out swift preventive action, the death tions were administered annually in are on the near horizon. However, as toll due to these diseases will continue developing and transitional countries with earlier HIV therapies, they are to rise. Tens of billions of dollars alone10 and that the habitual reuse extremely costly. A major campaign, have been invested effectively in the of needles and syringes accounted for similar to that carried out for treat- global attack on HIV/AIDS by the 2 million new HCV infections each ment of HIV, must be mounted to Bill and Melinda Gates Foundation, year (42% of new infections), 21 make such curative therapies generally the U.S. President’s Emergency Plan million new HBV infections per year available for those in low resource for AIDS Relief, UNAIDS, and The (33% of new HBV infections) and countries. Global Fund, among others. The same 260,000 new HIV infections (2% of groups plus Rotary International, the new infections)11,12,13. Fewer than 10% FIRST STEPS American Centers for Disease Control of injections were for vaccines and a This editorial has intentionally fo- (CDC), UNICEF, WHO and the large percentage of injections were cused on preventive measures. While Islamic Development Bank have actually unnecessary. Misconceptions introduction of broad based screening contributed additional billions to the concerning the belief that a syringe and regular ultrasound and alpha-fetal global eradication of Polio since 1988. could be safely reused if the needle protein (AFP) surveillance would These remarkable and laudable efforts was changed, a multi-dose vial or increase the early diagnosis of HCC, have had dramatic results in the fight infusion bag could be re-entered with and such approaches must be imple- against HIV/AIDS in the 34 million a used needle or syringe and a bag or mented for those currently at risk, individuals chronically infected with bottle of iv solution can be safely used early diagnosis will not benefit these HIV globally; and only 222 new cases multiple times have also led to mul- patients unless effective therapies are of polio occurred in only 3 countries tiple outbreaks of infections, includ- available. The costs of such therapies in 2012. A similar effort to elimi- ing in high resource western coun- and the medical facilities and practi- nate HCC, with a full bore attack tries. A major educational effort must tioners necessary to provide them will on hepatitis B and hepatitis C and be mounted to stop such practices. be prohibitive for many nations unless their 600 million chronically infected This must include patient education, a major global effort is mounted to patients (20 times more patients than since in many countries, especially underwrite such an effort, e.g. has those with HIV), is long overdue. in SE Asia, the Middle East and sub- been done for HIV and polio eradica- The lessons learned and infrastructure Saharan Africa, patients believe that tion. In the meantime, universal developed to eliminate HIV and polio injections are “stronger” and “more hepatitis B vaccination, reduction of must be applied to HCC, HBV, and 17 effective” than pills and demand them exposure to aflatoxin , strict infec- HCV. of their health care workers14,15,16. tion control measures, eliminating the The WGO and its foundation Additionally, not every country’s reuse of needles, syringes, etc., and (WGOF) will attempt to put the blood supply is entirely safe due to programs to make effective therapies spotlight on this long neglected irregular screening, especially for the for hepatitis B and C widely available epidemic in hopes of sparking greater hepatitis C virus. Finally, highly effec- should be achievable. Regional cam- recognition of the human tragedy paigns must be organized in a practi- caused by these inter-related diseases. cal way, based on available resources, In this battle it is critical to recognize and accurate epidemiological data that these diseases can be prevented must be collected in order to design and these diseases can be treated. But such programs. WDHD 2013 will it will require a major global effort attempt to collect such data through and investment by all affected parties. our 100+ national organizations and To see what is happening around discussions held at nine regional meet- the globe in support of this year’s ings scheduled throughout the year campaign, read the World Digestive during 2013. Health Day section in each issue of e- CONCLUSIONS WGN, and visit http://www.wgofoun- dation.org/wdhd-2013.html. The effects of HCC, along with hepatitis B and hepatitis C, are global 5 WORLD GASTROENTEROLOGY NEWS APRIL 2013

REFERENCES

1. Bosch FX, Ribes J, Díaz M, Cléries R. 7. McGlynn KA, London WT. The global 13. World Health Organization. Global Re- Primary liver cancer: worldwide inci- epidemiology of hepatocellular carcinoma: port: Global summary of the AIDS Epidemic dence and trends. Gastroenterology. 2004 present and future. Clin Liver Dis. 2011 2009. 2011 July. [Internet]. Available at Nov;127(5 Suppl 1):S5-S16. May;15(2):223-43. http://www.who.int/hiv/data/en/

2. Ferlay J, Shin H, Bray F, et al. GLOBO- 8. World Health Organization & Unicef. 14. Kermode M. Unsafe injections in CAN 2008, Cancer incidence and mortal- Global Immunization Data. October 2012. low-income country health settings: need ity worldwide: IARC CANCERBase no. 10 [Internet]. Available at http://www.who.int/ for injection safety promotion to prevent [Internet]. Available at http://globovan.iarc. immunization_monitoring/Global_Immuni- the spread of blood-borne viruses. Health fr. zation_Data.pdf Promot Int. 2004 Mar;19(1):95-103.

3. El-Serag HB, Rudolph KL. Hepatocel- 9. Global routine vaccination cover- 15. Miller MA, Pisani E. The cost of lular carcinoma: epidemiology and molecu- age, 2011. Wkly Epidemiol Rec. 2012 Nov unsafe injections. Bull World Health Organ. lar carcinogenesis. Gastroenterology. 2007 2;87(44)L432-5. 1999;77(10):808-11. Jun;132(7):2557-76. 10. World Health Organization, Media 16. Reeler AV, Hematorn C, WHO Action 4. Marrero JA. Multidisciplinary manage- centre: Injection safety. 2006 Oct; Factsheet Programme on Essential Drugs. Injection ment of hepatocellular carcinoma: where No. 231. [Internet]. Available at http://www. practices in the third world. A case study are we today? Semin Liver Dis. 2013 who.int/mediacentre/factsheets/fs231/en of Thailand. 1994;Geneva: WHO/DAP/94.8. Feb;33 Suppl 1:S3-10. Available at http://www.who.int/iris/han- 11. Hauri AM, Armstrong GL, Hutin YJ. dle/10665/60248 5. Yang JD, Roberts LR. Hepatocellular The global burden of disease attribut- carcinoma: A global view. Nat Rev Gastro- able to contaminated injections given in 17. Turner PC, Sylla A, Gong YY, Diallo enterol Hepatol. 2010 Aug;7(8):448-58. health care settings. Int J STD AIDS. 2004 MS, Sutcliffe AE, Hall AJ, Wild CP. Reduc- Jan;15(1):7-16. tion in exposure to carcinogenic aflatoxins by postharvest intervention measures 6. Perz JF, Armstrong GL, Farrington in west Africa: a community-based LA, Hutin YJ, Bell BP. The contributions of 12. Center for Disease Control and Pre- intervention study. Lancet. 2005 Jun hepatitis B virus and hepatitis C virus infec- vention. Hepatitis C information for health 4-10;365(9475):1950-6. tions to cirrhosis and primary liver cancer professionals. 2012 July;Factsheet No. 164. worldwide. J Hepatol. 2006 Oct;45(4):529- [Internet]. Available at http://www.who.int/ 38. mediacentre/factsheets/fs164/en/ Scientific News

6 WORLD GASTROENTEROLOGY NEWS APRIL 2013

An Introduction to Two Perspectives on Colorectal Cancer Prevention

This issue ofe-WGN includes two articles about the future of colorectal cancer prevention. Professor Dennis Ahnen (University of Colorado, USA) delivers the perspective from a high resource country and Professor Rene Lambert (Inter- national Agency for Research against Cancer, France) discusses colorectal cancer prevention in less resourceful countries. The two articles highlight important differences in disease dynamics and resource availability that may influence decision- making regarding screening and diagnosis of colorectal cancer. Emphasis is placed on westernization of lifestyles and age being most important determinants affecting prevalence of colorectal cancer. We think the two articles enhance our understanding of colorectal cancer as a global problem. They also illustrate the problems involved in selecting an optimal strategy for prevention of colorectal cancer in many parts of the world. We would like to take the opportunity to recommend readers to WGO’s global Practice Guideline on Colorectal Cancer Screening that can be downloaded from the WGO website.

Henry J. Binder, MD Greger Lindberg, MD United States Sweden e-WGN Co-Editor e-WGN Co-Editor Yale University Karolinska Institute 7 WORLD GASTROENTEROLOGY NEWS APRIL 2013

The Future of Colorectal Cancer Prevention in Developing Countries

the Caribbean, Melanesia, Micronesia René Lambert, MD and Polynesia. Some countries like Screening Group Brazil, Russia, India, China, not yet I.A.R.C, Lyon, France classified in the more developed group, are called “emerging” because of the fast development of their resources. Country resources have been classified in four categories by the World Bank3, according to the annual Gross The burden of colorectal cancer in (Cancer Incidence in V continents2 National Income (G.N.I.) “per capita”, the world and GLOBOCAN1), allows com- expressed in US Dollars. In 2011 the Over the world, colorectal cancer is parisons of the risk between countries G.N.I. per capita was $1,000, or less, the third most common cancer in having a different distribution in the in the Low Income group of coun- men, and the fourth in women. In the age classes of the population. Mortal- tries, $1,000 to $4,000, in the Lower IARC GLOBOCAN database1 inci- ity is the yearly number of deaths Middle Income group $4,000 to dent cases of colorectal cancer in 2008 in the corresponding population of $12,000 in the Upper Middle Income were estimated, for both genders, at 100,000 persons. The mortality rate group, and more than $12,000, in 1,234,000, out of which 727,000 are is also expressed as an ASR mortal- the High Income group. A more in developed countries and 506,000 ity/100,000 persons, in reference to precise classification is the Human are in developing countries. Colon the standard of the world population Development Index (H.D.I), based on cancer is located either in the proxi- in 1960. Survival is estimated from multiple parameters including G.N.I, mal segment (ascending colon and registries having a regular follow-up of education and years of school, health right angle), the transverse segment the cases included. The 5-year Relative education and living standard. and left angle, or the distal segment Survival (5y-RS) takes in account the 1) Incidence: Considerable varia- (descending colon and sigmoid). Rec- life expectancy of persons of the same tions in the incidence, of colorectal tal cancer is located distally between sex and age, not suffering from this cancer between regions, and countries the recto-sigmoid junction and the cancer. In addition the index of Dis- of the world depend on causal factors anal margin. ability Adjusted Life Years (DALY), in relation to development. In the In each region of the world the bur- based on incidence and mortality, GLOBOCAN, in 20081 the average den of colorectal cancer is estimated includes successive steps from cancer ASR incidence of colorectal cancer for in population based cancer registries. detection to death, with the years of 100,000 is much higher in More De- Observed data in cancer registries disability. DALY is expressed as the veloped (30.1/100,000) than in Less display precise information in the number of years lost/100,000 persons Developed countries (7.1/100,000). fraction of population concerned. For of the target population. As an example, in the more devel- the global population of a country es- oped countries, the respective figures timated figures are found in the 2008 Colorectal cancer in developing (both sexes) are 29.4/100,000 in edition of the IARC database GLO- countries France and 38.0/100,000 in Nor- BOCAN1. Incidence, or the annual In geographical regions of the world, way in Europe and 29.2/100,000 number of cases occurring in a corre- countries are also classified in refer- in the USA in North America, and sponding population of 100,000 per- ence to their development: more 31.5/100,000 in Japan in Asia. Lower sons is expressed as an age standard- developed countries predominate in figures occur in the less developed ized rate of Incidence (ASR)/100,000 all regions of Europe and in North countries as 14.2/100,000 in China persons which refers to a standard of America, Australia/New Zealand and in Asia, 6.5/100,000 in Mexico in distribution of age classes in the world Japan. Less developed countries are Central America, 9.8/100,000 in population in 1960. This standard, found in all regions of Africa, Asia Algeria, 5.9/100,000 in Uganda, and adopted in the IARC monographs (excluding Japan), Latin America and 5.4/100,000 in Zimbabwe in Africa. 8 WORLD GASTROENTEROLOGY NEWS APRIL 2013

2) Mortality: In 2008, the aver- in Less Developed countries of Africa 20108. In Japan, an Asiatic country age figure of the ASR mortality from where early detection is not frequent. classified in the same group, the ASR colorectal cancer was 12.0/100,000 incidence/100,000 of colon cancer in the More Developed countries and Causal factors of colorectal cancer increased from 8.3 in 1973-1977 to 6.0/100,000 in the Less Developed In a large majority of cases, cancer 36.0 in 1998-2002 for men, and from countries. Mortality is related to is a sporadic disease and the risk is 7.3 to 21.5 for women. This variation survival of colorectal cancer, which influenced by exposure to environ- correlates with ascending resources depends on the proportion of early mental carcinogenic factors, classified and development of a Westernized detection and curative treatment. The as toxic, infectious and linked to diet style of life. ratio of Mortality to Incidence rates and nutrition. This justifies a primary In Less Developed countries of is much lower in More Developed prevention of cancer through control Africa often classified in the Low In- countries (39%) than in Less Devel- of these factors connected to lifestyle come Group, the incidence of colorec- oped countries (84%). The respective and environment. Diet and nutri- tal cancer remains low in 2008, as rates of Incidence and of Mortality in tion play a determinant role in the shown in Table 1. On the other hand, different large regions of the world are risk for colorectal cancer, in relation in “emerging” countries, like Brazil displayed in Table 1, with the ratio to an excess of calories ingested with and China, the incidence of colorectal of Mortality to Incidence. The lowest a high proportion of red and pro- cancer correlates to the progression ratio is for North America region, and cessed meat and fat. The altered diet of the country income and a rapid the highest ratio is for Africa. is associated to overweight, resistance increase is expected in relation to the 3) Survival: In cancer registries to insulin and production of insulin- progression of their resources and with a regular follow-up, the five year like growth factors, like the IGF-1 the urbanized style of life. However, survival of the cases included can be which stimulates the proliferation of a different situation occurs in India9 5,6,7 determined. Survival depends on the intestinal cells . A sedentary lifestyle where a spontaneous prevention is af- early diagnosis and proportion of cas- with decreased physical activity is a forded by the generalized practice of a es detected at a curable stage. At the frequent associated causal factor. In vegetarian diet, with enough physical country level, survival from colorectal more developed countries, these fac- activity; in 1998-2002, the respective cancer is analyzed in period 1990-94 tors that closely relate to the develop- figures of the ASR incidence/100,000 in the CONCORD study4. The re- ment of resources and urbanized life of colorectal cancer in men and spective 5y-RS for men and women is likely explain the higher incidence of women in the IARC database “Cancer high in 1990-94 in the USA at 51.9% colorectal cancer. In the UK, a Euro- Incidence in V Continents” were still and 60.2%, and in Japan, at 61.1% pean country classified in this group, low at 5.9 and 4.4 in the urban regis- and 77.3%. Screening is developed the proportion of colorectal cancer try of Mumbai, and 4.1 and 3.6 in the in both countries. In contrast, the attributable to lifestyle and environ- rural registry of Karuganappally2. The 5y-RS is low, in the range 10% - 20% mental factors, is estimated at 54% in incidence of colon cancer remained stable and low in the Urban Mumbai registry, during the period 1973 to Ratio of Mortal- Region of the World Incidence Mortality ity/Incidence 2002 in spite of the development of the city. Northern America 30.1 9.1 30.2% Europe 28.1 12.8 45% Perspective on evolution of the Eastern Asia 18.0 8.0 44% burden of colorectal cancer Western Pacific Asia 17.9 7.9 44% The worldwide burden of colorectal cancer will increase in the next few Latin America and Caribbean 11.4 6.6 57% decades in relation to the increase South East Asia 6.9 4.8 69% in the world population and in the Africa 5.9 4.8 78% proportion of older age groups. An estimation of the variation expected Table 1: Estimated Age Standardized rate of incidence and mortality for colorectal cancer, in in 2030 is given in GLOBOCAN1: - 2008 in a population of 100,000 persons, for both sexes, in different regions of the world. In addition is given the ratio of the mortality to incidence rates. the annual number of incident cases From IARC GLOBOCAN database in 2008. worldwide, in 2008 for both sexes is estimated at 1,235,198 with 59% of cases over 65 years. In 2030 the 9 WORLD GASTROENTEROLOGY NEWS APRIL 2013

N° incident cases N° expected requiring material and experience, to Country in 2008 in 2030 be performed only in persons positive Algeria 2,619 5,364 (+106%) to the first test. Endoscopic proce- Brazil 21,768 42,447 (+ 95%) dures, either with flexible sigmoidoscopy or complete colonoscopy, will India 36,476 66,80I (+ 83%) confirm the presence of the lesion and China 221,313 400,086 (+ 81%) eventually proceed to the resection of USA 155,881 247,442 (+ 61%) a superficial cancer or a premalignant France 38,394 55,344 (+ 42%) adenoma. Repeated screening trials for Japan 101,656 129,974 (+ 28%) colorectal cancer are often offered Table 2: Estimated number of incident cases occurring in 2008, in both sexes and projected number of cases in 2030, based on population growth and ageing in some countries of the world. in Developed Countries in Europe, From IARC GLOBOCAN database. North America and in Japan, to persons in the age range 40 to 70 years. The policy of secondary prevention deserves to be generalized in the De- veloping Countries. The incidence of expected number of incident cases in resources: in 2030, incident cases colorectal cancer is still low in the less should be 2,179,771, with 65% in are expected to increase by 95%. In developed countries of the world, but the age classes from 65 years. At the conclusion, in developing countries the impact of delayed diagnosis and level of a single country the varia- increased income will correlate with poorly adapted treatment increases the tion depends of multiple factors: 1) increased risk of colorectal cancer with global burden of cancer, with impact The structure of its population in age modifications based on variations in on survival and mortality. classes in 2008, and the birth rate; 2) the nutrition and physical activity of 1) The Role of Health The perspective in development and the populace. Authorities: As a rule, in each country, increased resources of the country; the prevention of cancer is under con- Perspective on screening and early and 3) The strategy adopted for trol of a National Health Service, like detection of colorectal cancer screening and treatment of precursors. in the UK, or of a Ministry of Health Primary prevention of colorectal can- Considerable differences occur be- and Family Welfare; like in India. For cer is based on a reduction of ingested tween countries, as shown in Table 2. prevention of colorectal cancer, the calories and increase in physical activ- As a More Developed country, Japan National Authorities should actively ity. This prescription has an impact already has an aged population, stable encourage the control of environ- on weight and obesity. In perspective resources, and an established policy of mental carcinogenic factors, linked to the control of nutrition and diet is screening; as a consequence, incident diet with excess in calories and lack necessary in developing or in “emerg- cases of colorectal cancer during the of vegetables and the development of ing” countries as well as in the more period 2008-2030 are expected to physical activity. The organization of a developed countries. increase only by 28%. screening policy of secondary preven- To complement primary preven- In developing countries, a major tion also depends on the National Au- tion, secondary prevention aims to increase in the incidence of colorec- thorities. Developing Countries with reduce the number of incident cases tal cancer is expected if they have low resources have not yet structured by the destruction of premalignant a young population and increasing their National Health Care System. adenomatous precursors and early resources. In these countries a policy “Emerging” countries with higher detection of cancer at a curable stage. of prevention of colorectal cancer resources, have already built Health Screening modalities for the selection is justified. This applies particularly Care structures and cancer control in of asymptomatic persons susceptible to emerging countries like Brazil, urban areas; but heterogeneity persists to harbor neoplastic colorectal lesions India, and China; however, in India, with a lower impact in rural than in include two distinct steps: 1) A simple spontaneous primary prevention is urban areas. In developing countries preliminary filter test like the detec- provided by the generalized practice of with low resources, any progress in tion of fecal occult blood, with an a vegetarian diet with enough physi- the prevention of colorectal cancer acceptable compliance and a negative cal activity. In the group of emerg- will also require the establishment of a or positive response; and 2) A more ing countries, Brazil has a relatively National Policy of Health Care. young population and a fast increase complex endoscopic exploration, 10 WORLD GASTROENTEROLOGY NEWS APRIL 2013

2) The Fecal Occult Blood Test: The ered as not justified; however, when 30% for all adenomas. Fecal Occult Blood Test (FOBT), is a the incidence increases in relation b) As a second procedure, per- filter test, repeated at 2-year inter- to development of the country the formed after a positive filter vals10. Colonoscopy is proposed to screening protocol should be devel- FOBT in organized Mass Screen- persons positive to this filter test. The oped. However, filter tests with mo- ing protocols. In the National global sensitivity of FOBT is around lecular markers of cancer are still very Polyp study conducted in the 50% for colorectal cancer and much costly, and it is unlikely that they will USA the reduction of the risk lower, around 20%, for adenomas, be deployed in Developing Countries. of colorectal cancer in persons with a significant proportion of false 3) Flexible Sigmoidoscopy: Flexible submitted to a colonoscopy was positive reactions. In spite of some de- sigmoidoscopy explores distal large estimated at 75%. bate about efficacy, the capacity of the bowel with rectum and sigmoid. The Numerous screening trials have FOBT protocol to reduce colorectal procedure can also be performed by confirmed the reduction in mortality cancer mortality, has been confirmed trained nurses. Guidelines on screen- from colorectal cancer after colonos- in the period 1990-2000, by three ing recommend that flexible sigmoid- copy, in spite of false negative pro- randomized trials in the USA, UK oscopy be repeated 5 years after an cedures, resulting two or three years and Denmark, with a reduction of initial negative procedure. A cohort later in a so-called “interval” can- 15% in colorectal cancer mortality, study conducted in 24,744 health cer14,15. The endoscopic resection of but no impact on incidence. Overall professionals in the USA has shown adenomas has also an impact on the screening with the FOBT test ensures that screening flexible sigmoidoscopy incidence of colorectal cancer. In the a reduction in colorectal cancer mor- reduces mortality from colorectal can- USA SEER Registries13, during the tality of 15%, reaching 23% when cer by 50%, and incidence by 44%. period 1975/2003, the ASR incidence adjusted for individual attendance. In perspective, flexible sigmoidos- of colorectal cancer decreased by The Guaiac FOBT is progressively copy could offer a valuable protocol 19.4%, presumably as a consequence replaced by a more specific immuno- for colorectal cancer screening in of the increased utilization of endo- chemical test (I-FOBT) based on hu- Developing Countries classified by scopic treatment of their precursors. man hemoglobin. Molecular markers their G.N.I. in the Low Income group Colonoscopy is currently performed of colorectal cancer, now developed or in the Lower Middle Income group in the More Developed countries in through proteomics and genetics, because of a better acceptance than organized Mass Screening protocols should replace FOBT in the near colonoscopy and a lower cost. in persons with a positive response to future in organized screening proto- 4) Colonoscopy: is the gold stan- a filter FOBT. However compliance cols. DNA tests with a high sensitiv- dard procedure for the early detection is limited, cost is high and there is a ity, based on molecular markers of the of colorectal cancer and premalignant small toll of severe complications. In k-ras gene, are now available as stool adenomatous polyps, which can be perspective, colonoscopy tends to be tests11. Circulating micro-RNAs also resected, preventing the later devel- performed more often as a primary offer a large opening on easy screen- opment of a cancer. The endoscopic test in opportunistic non-organized ing with a simple blood sample12. destruction of premalignant precur- screening for asymptomatic persons These tests, not yet cost-effective, are sors achieves a reduction of cancer asking for prevention. In the USA expected in the near future to replace incidence, as shown in the SEER colonoscopy every 10 years, from age in Mass Screening protocols the stool registries of the USA13: the ASR inci- 50 years is proposed without filter test samples of FOBT by a simple blood dence/100 000, both sexes, decreased as an alternative to Mass Screening. sample. from 64.2 in 1985, to 60.6 in 1990 In addition Virtual colography with a Organized Mass Screening proto- to 49.5 in 2003. Colonoscopy can be 3D-multidetector scanner is an alter- cols with the FOBT test are proposed proposed in two situations: native to primary colonoscopy in non to the population of asymptomatic a) As a primary procedure, without organized screening; however colonos- persons of both sexes in the age 50 to a filter test, in non organized, copy has to be performed when there 70 years, by the Health Authorities, in or “opportunistic screening”. In is an abnormal finding. the majority of Developed Countries a group of average risk persons, In Developing Countries, the risk in North America, Europe and Japan. aged 50 years or more, the yield of colorectal cancer may increase, con- As yet, the risk of colorectal cancer is of colonoscopy is under 1% for trasting with a persistent weakness in lower in Developing Countries and cancer, under 10% for advanced organized Mass Screening, under con- Mass Screening protocols are consid- adenomas, and in the range 25 to trol of Health Authorities. The discrep- 11 WORLD GASTROENTEROLOGY NEWS APRIL 2013

ancy should encourage the growth of opportunistic indications for primary 9. Sankaranarayanan R, Swaminathan R, REFERENCES Eds .Cancer survival in Africa, Asia, the colonoscopy in spite of its high cost. Caribbean and Central America: IARC However this is not a population-based Scientific Publications N° 162, IARC, Lyon, 1. Ferlay J, Shin HR, Bray F, Forman D, 2011. strategy of prevention. Mathers C, Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: Conclusion on screening IARC CancerBase No. 10 . IARC Lyon; 2010. 10. Heresbach D, Manfredi S, D’halluin PN, strategies Available from: http://globocan.iarc.fr. Bretagne JF, Branger B. Review in depth and meta-analysis of controlled trials on Implementation of screening measures colorectal cancer screening by faecal oc- in a country depends on Health Au- 2. Curado MP, Edwards B, Shin HR, Storm cult blood test. Eur J Gastroenterol Hepatol. thorities, reimbursement facilities, and H, Ferlay J, Heanu M, et al. eds Cancer 2006; 18:427-33. Incidence in Five Continents, Vol. IX, IARC compliance of the population. In the Scientific Publications No. 160, IARC, Lyon, Developed Countries of Europe and in 2007 (and previous editions). 11. Imperiale TF, Ransohoff DF, Itzkowitz Japan mass screening with the FOBT SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in is proposed to the population and re- 3. World Bank list of economies (April 2012) an average-risk population. N Engl J Med. imbursed, Germany and Italy also have at: http://shop.ifrs.org/files/CLASS.pdf 2004; 351:2704-14. organized screening protocols based on and List of Countries by GDP (nominal) per capita. At http://en.wikipedia.org/wiki/. primary colonoscopy. Screening with 12. Ahmed FE, Amed NC, Vos PW, et al.. Diagnostic microRNA markers to screen for primary sigmoidoscopy is encouraged 4. Coleman MP, Quaresma M, Berrino F, in Scandinavian countries and in the sporadic human colon cancer in blood. Can- Lutz JM, De Angelis R, Capocaccia R, et al. cer Genomics Proteomics. 2012; 9:179-92. UK with nurse endoscopists. In the Cancer survival in five continents: a world- USA the Medicare policy recommends wide population-based study (CONCORD). Lancet Oncol. 2008; 9: 730-56. 13. SEER Cancer Statistics Review, 1975- annual FOBT or sigmoidoscopy every 2008, National Cancer Institute. Bethesda, five years or colonoscopy every 10 MD, http://seer.cancer.gov/csr/1975_2008/. 5. Lund Nilsen TI, Vatten LJ. Colorectal can- years. In studies of the cost/effective- cer associated with BMI, physical activity, ness ratio, the screening of colorectal diabetes, and blood glucose. IARC Sci Publ. 14. Brenner H, Chang-Claude J, Seiler CM, cancer is placed in the USA well under 2002; 156:257-8. Hoffmeister M. Interval cancers after negative colonoscopy: population-based case- the financial benchmark adopted in control study. Gut. 2012 Nov;61(11):1576- screening ($40,000 per year of life 6. Wolin KY, Yan Y, Colditz GA, Lee IM. 82. gained). Developing countries with Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer. 2009; increasing resources should develop 100(4):611-6. 15. Steele RJ, McClements P, Watling C, a policy of prevention of colorectal et al. Interval cancers in a FOBT-based colorectal cancer population screening cancer based on population-based 7. Boffetta P, Couto E, Wichmann J, Ferrari programme: implications for stage, gender screening interventions with the less P, Trichopoulos D, Bueno-de-Mesquita HB, and tumour site. Gut- 2012, 61, 576-581. costly FOBT, and over time to primary van Duijnhoven FJ, et al.. Fruit, vegetables, and colorectal cancer risk: the European endoscopy, with flexible sigmoidoscopy Prospective Investigation into Cancer and being the priority. Nutrition. Am J Clin Nutr. 2009; 89:1441-52.

8. Parkin DM, Boyd L, Walker LC. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer. 2011;105 Suppl 2:S77-81. 12 WORLD GASTROENTEROLOGY NEWS APRIL 2013

The Future of Colorectal Cancer Prevention in the United States A perspective from a high burden, sufficient resource country

not encouraging, the decline in smok- Dennis J. Ahnen, MD ing rates has stabilized, there is little Staff Physician, Eastern Colorado Health Care System evidence the we are eating a healthier Professor of Medicine, University of Colorado School of Medicine Denver, Colorado, USA diet and rates of obesity and physical inactivity are still increasing. Efforts that successfully address these risk factors could substantially decrease CRC risk but there is little doubt that screening will continue to be the ma- Colorectal cancer (CRC) is one of prevention success stories of the last jor CRC-specific preventive strategy the most common cancers with over 30 years. Both CRC incidence and for the foreseeable future. In a similar 1.2 million new cases of colorectal mortality have been steadily decreas- way, chemoprevention, particularly cancer and more than 600,000 deaths ing and CRC deaths have been cut with aspirin and other NSAIDs, has worldwide per year. CRC is the fourth in half since 1975. It is tempting great promise as an adjunct to screen- most common cause of cancer death to attribute these decreases to CRC ing but chemoprevention will not and the second most common cancer screening but the decreases started replace screening in the foreseeable in the world and the best estimates are well before screening for CRC was future. that the rate will continue to increase widely used. The best estimates are In the US, thinking about CRC substantially over the next decade1. that about half of the decreases have screening has been evolving from the There is substantial variability in CRC been due to screening and the rest due concept of early detection of cancer incidence (10 fold) and mortality to changes in risk factors along with toward CRC prevention by identifica- (5-6 fold) among countries with rates some improvement in treatment. tion and removal of colonic polyps. continuing to increase in many devel- Some future trends seem certain. As this trend continues it will benefit oping countries while they are stable The demand for CRC prevention screening tests that can identify ad- or decreasing in some developed efforts will continue to rise as the vanced adenomas with relatively high countries1, particularly those that have 50-75 year old population is projected sensitivity such as endoscopic or ra- substantial CRC screening programs. to slowly grow in the US over the diologic imaging tests and the higher Winawer et al2 have presented the next 35 years. It also seems likely that sensitivity fecal occult blood tests. concept of Cascade CRC Screening whatever screening/prevention choices Colonoscopy will likely continue Guidelines among countries that are are made, the recent favorable trends to be the dominant method of colon evidence based and resource driven2. in CRC incidence and mortality will cancer screening in the US, at least in The guidelines suggest that countries continue; the uncertainty is what the the near future. Colonoscopic screen- like the US that have a high CRC magnitude of the future decreases will ing for CRC has great appeal; it is the burden and have sufficient (at least be. CRC screening rates have been only currently available colon screen- for now) resources might opt for colo- steadily increasing in the US for the ing test that can both identify and noscopy as a major screening option last 25 years; currently almost 70% of remove colonic polyps in the entire whereas countries with substantial the population is being screened and colon in a single procedure. Currently CRC burden but severely limited colonoscopy is by far the dominant clinical and financial incentives in resources might opt for fecal occult screening strategy. We will, no doubt, the US strongly favor colonoscopic blood testing as the only affordable continue to see the benefit of this high screening. Primary care physicians in screening approach. and increasing screening rate over the the US overwhelmingly view colo- CRC time-trend data in the US next decade or longer. In contrast, noscopy as the “best” colon cancer illustrate one of the great cancer trends in some CRC risk factors are screening option and are concerned 13 WORLD GASTROENTEROLOGY NEWS APRIL 2013

The more serious threats to colonoscopic screening/surveillance are the cost increases that are not associated with improved outcomes. Colonosco- py screening and surveillance intervals recommended by endoscopists are often shorter than those recommended by the current guidelines8, and there has been a marked increase in the use of anesthesiology services to provide sedation for endoscopy9 and some groups have incorporated anesthesiology and pathology services as part of the revenue streams of their endoscopy units. These practice patterns can all lead to substantially increased costs of colonoscopy without evidence of patient benefit. If colonoscopy is going to be replaced, the change will likely be

driven by Accountable Care Orga- FigFig 1. 1. Trends Trends in in Colorectal Colorectal Cancer Cancer Mortality Mortality Rates Rates for for Select Select CountriesCountries in Males,Males, 1985 1985 Through Through nizations or similar groups who will 2005.2005. Source: Source: WorldWorld Health Health Organization Organization Mortality Mortality Database. Database. Available Available at: at: http://www-dep.iarc. http://www- frdep.iarc.fr/. Accessed/. Accessed December December 15, 2008. 15, Reprinted 2008. Reprinted from Reference from Reference 1 with permission. 1 with permission. have responsibility for costs of overall health care of a population. The strongest initial challenge will likely that doing anything less would leave ing that colonoscopy did not have come from fecal immunochemical them legally liable for failure to prop- any protective effect for right sided testing. Modeling studies suggest erly screen for CRC. Colonoscopic colorectal cancers4, 5. Fortunately, that FIT, if done annually, would be screening has the added advantage of colonoscopy quality appears to be im- as effective as colonoscopy,10 and the satisfying the CRC screening require- proving. Reported adenoma detection cost of the test itself is about 1% that ment for up to 10 years and shifting rates are increasing and it is reassuring of colonoscopy. There will, however, some of the responsibility for screen- that recent studies have shown that be substantial costs associated with ing from the primary care provider colonoscopy was associated with a trying to assure annual adherence to the endoscopist. For endoscopists, decreased right sided CRC risk albeit to FIT. Controlled trials comparing colonoscopy is satisfying both clini- less than that for left sided cancers6, 7. colonoscopy to annual FIT have been cally and financially and until recently The apparent increase in adenoma initiated but results won’t be final for payers have largely passed the higher detection rates is an indicator of at least a decade. cost of colonoscopy to employers, improving colonoscopy quality but it Gastroenterologists can and should taxpayers or the individual purchaser. also raises a clinical paradox. Im- lead the CRC prevention effort In the longer term, colonoscopic proved colonoscopy quality should providing the best risk stratification screening is at serious risk of being lead to a lower future CRC risk for and modification and by using the replaced for two major reasons; vari- the screened group but it will also lead best prevention and screening tools ability in colonoscopy quality and to substantially increased surveillance available, including providing high cost. There is substantial evidence intensity of the now lower-risk group. quality colonoscopy without excessive that colonoscopy quality is variable. As more adenomas are found, more costs. Such an approach will be good Adenoma detection rates, an accepted patients will move from screening to for our patients and what is good for measure of colonoscopy quality, vary surveillance and more will move from our patients will ultimately be good substantially among endoscopists3. 5-10 year to 3 year surveillance inter- for Gastroenterology. There is particular concern about the vals leading to a substantial increase in quality of colonoscopy in the right costs unless surveillance recommenda- colon with some earlier studies report- tions are adjusted. 14 WORLD GASTROENTEROLOGY NEWS APRIL 2013

REFERENCES 5. Brenner H, Hoffmeister M, Arndt V, et 9. Inadomi JM, Gunnarsson CL, Rizzo JA, al: Protection from right-and left-sided Fang H. Projected increased growth rate of colorectal neoplasms after colonoscopy: anesthesia professional-delivered sedation 1. IARC Database. 2008 Lyons, France Glob- Population-based study. J Natl Cancer Inst for colonoscopy and EGD in the United can http://globocan.iarc.fr/factsheet.asp. 102: 89-95, 2010. States: 2009 to 2015. Gastrointest Endosc. 2010 Sep; 72(3): 580-6. 2. Winawer SJ, Krabshuis J, Lambert R, 6. Brenner H, Haug U, Arndt V, et al: Low O’Brien M, Fried M; World Gastroenterol- risk of colorectal cancer and advanced ad- 10. Zauber AG, Lansdorp-Vogelaar I, ogy Organization Guidelines Committee. enomas more than 10 years after negative Knudsen AB, Wilschut J, van Ballegooijen Cascade colorectal cancer screening colonoscopy. M, Kuntz KM. Evaluating Test Strategies for guidelines: a global conceptual model. J Colorectal Cancer Screening—Age to Begin, Clin Gastroenterol. 2011 Apr; 45(4): 297- Age to Stop, and Timing of Screening 300. Review. 7. Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP. Association between Intervals: A Decision Analysis of Colorectal colonoscopy and colorectal cancer mor- Cancer Screening for the U.S. Preventi- 3. Rex D.K., Hewett D.G., Snover D.C.: Edito- tality in a US cohort according to site of ve Services Task Force from the Cancer rial: Detection targets for colonoscopy: cancer and colonoscopist specialty. J Clin Intervention and Surveillance. Modeling from variable detection to validation. Am J Oncol. 2012 Jul 20; 30(21): 2664-9. Network (CISNET) [Internet]. Rockville (MD): Gastroenterol 105. 2665-2669.2010. Agency for Healthcare Research and Qual- ity (US); 2009 Mar. 8. Ransohoff DF, Yankaskas B, Gizlice 4. Baxter NN, Goldwasser MA, Paszat LF, et Z, Gangarosa L. Recommendations for al: Association of colonoscopy and death post-polypectomy surveillance in commu- from colorectal cancer. Ann Intern Med nity practice. Dig Dis Sci. 2011 Sep; 56(9): 150:1-8, 2009. 2623-30. Letter to the Editors

15 WORLD GASTROENTEROLOGY NEWS APRIL 2013

Letter to the Editors: Gallstone Disease – a Heavier Burden in India!

Vinay K. Kapoor, FRCS, FACS, FACG Professor of Surgical Gastroenterology Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS) Lucknow, India

I have read with interest the article was higher in some ethnic groups ‘The Growing Global Burden of Gall- (Punjabis 7.4% and Gujaratis 7.4%) REFERENCES stone Disease’ by Monica Acalovschi than other (Bengalis 4.4% and South and Frank Lammert in World Gastro- Indians 1.8%). Not only the differ- 1. Kapoor VK, McMichael AJ. Gall bladder enterology News December 2012: 6-9. ence in prevalence of GSD, the type cancer – an Indian disease. National Medi- The Authors have unfortunately of GS also differs between north and cal Journal of India 2003; 16: 209-213. missed India, the second most popu- south India. While most (80-90%) lous country on the globe, with a pop- GS in north India were cholesterol 2. Khuroo MS, Mahajan R, Zargar SA, Javid ulation of more than 1.2 billion and (75% of dry weight as cholesterol), G, Sapru S. Prevalence of biliary tract disease in India: a sonographic study in adult huge ethnic diversity. Gallstone dis- GS in south India were predomi- population in Kashmir. Gut 1989; 30(2): ease (GSD) is common in India and nantly (60-70%) pigment stones 201–205. also and shows differences between (<20% of dry weight as cholesterol) North and South. In a retrospective (Tandon 1994). GSD starts at a much 3. Malhotra SL. Epidemiological study of survey of railroad workers (between younger age in India than in the west. cholelithiasis among railroad workers the ages of 18 and 55 years), Malhotra In the survey by Khuroo et al (1989), in India with special reference to causation. Gut 1968; 9: 290-295. (1968) found that GSD (diagnosed the prevalence of GSD in women was by oral cholecystography OCG and at 4.9% in the age group of 21-30 years, 4. Tandon RK. Studies on pathogenesis of operation) was as many as seven times 15.0% in 31-40, 16.5% in 41-50 and gallstones in India. Ann Natl Acad Med Sci more common in north India than in 29.1% in 51-60 years. (India) 1989; 25: 213-222. south. In an ultrasonographic (US) The prevalence rates of GSD paral- survey of 1,104 subjects more than lel the incidence rates of gall bladder 5. Tandon RK, Thakur VS, Basak AK, Lal K, 15 years of age in Srinagar, the capital cancer (GBC). In India too, while Jayanthi V, Nijhawan S. Pigment gallstones predominate in South India. Indian J Gas- of Jammu and Kashmir state in north GBC is very common (incidence rate troenterol 1994; 13(Suppl 1): 81(A-E6). India, Khuroo et al (1989), found the of about 10 per 100,000 per year in prevalence of GSD to be 6.1% (3.1% women) in the north, it is uncom- in men and 9.6% in women). In an- mon (incidence rate of less than 1 per other US survey of 1,104 subjects in 100,000 per year in women) in the Delhi, again in north India but with south. more cosmopolitan population, Tan- GSD is a heavier burden in north don et al (1989) found the prevalence India because of its association with of GSD to be 4.3%. The prevalence GBC. World Congress

16 WORLD GASTROENTEROLOGY NEWS APRIL 2013

GASTRO 2013 APDW/WCOG Shanghai News

View the Scientific Program Online TODAY! A dynamic, stimulating and varied scientific program of the highest quality will be presented, taking a global perspective while recognizing the special concerns of the Asian Pacific region. The Gastro 2013 Scientific Program can be viewed online at www.gastro2013.org.

View the Scientific Program at a Glance on the Gastro 2013 website.

Among the many highlights, the tion during Gastro 2013 APDW/ Program, which combines a full WCOG Shanghai. one-day Postgraduate Course/Live Authors are encouraged to regis- Demonstration Endoscopy Program ter for the Congress via the Online with the three day Main Meeting Registration system at the same time will result in a golden opportunity they submit abstracts. To register for to be informed of the latest scien- the Gastro 2013 APDW/WCOG tific achievements, to discuss recent Shanghai Congress, CLICK HERE. discoveries, and finally to renew both professional and personal friendships General Abstract Submission with peers from around the world. Information Abstracts must be submitted online Abstract Submission is NOW OPEN! via the online Abstract Submission The Gastro 2013 Scientific Program website before 29 April 2013, 23:59 Committee invites Congress Partici- GMT/UTC +8 hours. Visit the Gastro 2013 website to download a copy of the official Gastro 2013 Call for pants to submit an abstract of original It is recommended that you fully Abstracts today! work for consideration for presenta- review the information and guidelines 17 WORLD GASTROENTEROLOGY NEWS APRIL 2013

Important Online Registration Deadlines Regular Registration Deadline: 15 August 2013 Onsite Registration will begin on 16 August 2013

presented on the Abstract Submis- tions close to the Congress Venue or evening, at the Bund, a picturesque sion system or in the official Call for in the City Center at special rates for riverfront promenade, and expand Abstracts. Gastro 2013 participants. To view your journey outward through the a listing of recommended hotels for city. You will find that Shanghai has Gastro 2013 APDW/WCOG your visit to Shanghai please visit the an eclectic mix of modern culture, Shanghai Registration is NOW official Congress website atwww. such as the shops along Nanjing OPEN! gastro2013.org. Road, and deep-rooted tradition We will be delighted to welcome you Reserve your transportation services found within the many venerated sites to Shanghai for Gastro 2013 APDW/ today! A detailed listing of transporta- such as, the Temple of Jade Buddha, WCOG Shanghai and hope that you tion services that are available to book Yuyuan Garden, and the Longhua will elect to be part of this outstand- can be found on the Gastro 2013 Temple. You will soon see that Shang- ing scientific program in this excep- website at www.gastro2013.org. Both hai is a city alive with excitement! tional city. Don’t miss this unique hotel accommodations and transpor- The Congress offers a variety of opportunity to take part in this tation services can be booked during tours for tourists of all kinds. To view a important meeting. the Congress registration process. listing of tours, please visit the Gastro Registrations will only be accepted 2013 website at www.gastro2013.org. through the Online Registration Congress Tour Information system. Please CLICK HERE to go to The city of Shanghai will be an ideal For More Information the Gastro 2013 Online Registration setting for Gastro 2013. We encour- Visit www.gastro2013.org day or system now. age you and those who accompany night for updates and complete infor- you to tour our great city during your mation regarding the Congress. The Gastro 2013 Housing and visit. You will have a multitude of op- website will be updated regularly with Transportation Information portunities to experience the culture the most up-to-date information as it The Congress has selected a variety of and history of Shanghai. You may becomes available. If you would like hotels in nice and convenient loca- want to begin your journey, by day or to receive notifications regarding Gas- tro 2013, join our mailing list! Simply visit, www.gastro2013.org, scroll to the bottom of any Gastro 2013 web- page and enter your email address in the “be added to the congress mailing list” submission box. Gastro 2013 will send you reminders as deadlines draw closer and the latest news regarding the Congress. Gastro 2013 is on Facebook and Twitter; follow us on Twitter and like us on Facebook by visiting the Gastro 2013 website.

A view of the Shanghai skyline. Join us in Shanghai for Gastro 2013! September 21-24

SIGNEA’s Quadrennial Congress will be held in Shanghai, China September 21-24, 2013.

Held in conjunction with Gastro 2013 APDW/WCOG Shanghai. Contact us at [email protected] or visit the meeting website at www.gastro2013.org. WDHD News

19 WORLD GASTROENTEROLOGY NEWS APRIL 2013

World Digestive Health Day 2013 LIVER CANCER: ACT TODAY. SAVE YOUR LIFE TOMORROW. AWARENESS. PREVENTION. DETECTION. TREATMENT.

Another successful World Digestive approach to the prevention, detec- Health Day (WDHD) is well under- tion and treatment of hepatocellular way. Events have been taking place carcinoma (HCC) and its underlying since 2012 in support of the 2013 causes. theme, LIVER CANCER: Act Today. Save Your Life Tomorrow. Aware- 2013 WDHD Highlighted Event ness. Prevention. Detection. Treatment. PAKISTAN with many more to come. The 2013 Hepatitis Awareness Program WDHD seeks to raise awareness of Awareness screening and this growing health crisis and reduce vaccination camp @ Khyber, Hyderabad the number of individuals affected Participants attend the awareness, screening by supporting the worldwide fight to On the morning of February 2, 2013, and vaccination camp in Khyber, Hyderabad. bring recognition through education an awareness, screening and vaccina- and training concerning this disease. tion camp was arranged jointly by Mr. Adeel Khan, marketing man- Prevention, early detection, treat- AIMS Hospital and AGA KHAN ager of AIMS hospital, distributed the ment, and curability, supported by HEALTH Services. The Chief Minister awareness materials regarding chronic relevant epidemiological and clinical of the program for the prevention and hepatitis B and C both in Urdu and data, will be the main focus of the treatment of hepatitis B and C man- Sindhi. The participants and attendees 2013 campaign. Through a multi- agement team screened 1,000 people appreciated the efforts taken by the faceted approach, to include local and and the first vaccine was inoculated to program manager for the prevention regional campaigns and conferences, an HBSAg negative subject. and management of hepatitis B and the WDHD 2013 campaign will Professor Sadik Memon from C in Sindh and for his team for HBV endeavor to inform healthcare provid- (ISRA) AIMS Hospital delivered a and HCV vaccines - three doses for ers and the community at large of the comprehensive talk regarding the HBV each individual. prevalence, risk factors, and causes and HCV management. The major- During the last part of the day, of liver cancer and to present an ity of people who came were HBV or Professor Memon agreed to do free evidence-based and patient-centered HCV positive. The session became consultations for those individuals interactive once the audience started that tested positive and AIMS research asking interesting questions. laboratory offered, at very reason- Professor Memon answered the able prices, PCR (HCV & HBV viral questions in detail and added that the load) testing. only way to get rid of Viral Hepatitis is awareness in regard to the spread and WDHD 2013 Calendar of Events: risk factors for the diseases. Those that Past, Present, and Future were positive planned to have a sono- gram of their abdomen, routine blood Egypt tests, liver function tests and PCR Multiple presentations on HCC have testing (in the case of treatment seeking taken place including two during the th individuals). Dr. Tahir, Dr. Saghar and 5 Hepatology and Gastroenterology Professor Dr. Sadik Memon delivers a talk on Post Graduate Course on December the management of HBV and HCV. Dr. Sikandar worked day and night for the arrangement of this camp. 8, 2012 in Cairo titled “Medical 20 WORLD GASTROENTEROLOGY NEWS APRIL 2013

Management of Advanced Hepatocel- USA Venezuela lular Carcinoma” and “Hepatitis C 1. A presentation was given by 1. Various activities will be taking and Cryoglobulinemia; An Update”, WDHD Chairman Dr. Douglas place at the Hospital Universitario and another in February 2013 during LaBrecque on February 5 in Califor- from February through May, 2013. A the 16th International Congress of the nia titled “World Digestive Health meeting with the community “How Egyptian Hepato-Pancreato-Biliary Day 2013-Liver Cancer.” Goals of to Prevent Liver Cancer” took place Society in Hurghada. the program included making those in February, an exhibition by medical aware of the burden of liver disease students for the community will take Kazakhstan in the United States and the steady place in April, and a Walk For Health A WDHD 2013 conference will be and rapid rise in incidence of HCC, will take place on May 19. Education- held June 6 in the city of Almaty, including the fact that most cases al materials are also being developed through the National Gastroenter- are diagnosed only at an advanced in support of the campaign. ology Association of Kazakhstan, stage; recognizing the critical role of 2. A symposium on “How to Get under the direction of Professor Roza the primary care health provider in to Hepatocarcinoma”, coordinated by Bektayeva. addressing this national public health Dr. Maribel Lizarzabel, will be held Portugal problem; and becoming aware of the on May 23. It will include lectures on: A conference on “HCC: Global global health crisis due to liver disease, “From Hepatitis B and C to HCC. Warning, Global Answers” will take especially viral hepatitis and HCC, Involved Mechanisms”, “Alcoholism place May 31. and place the severity of this health and Its Relationship with Cirrhosis problem in perspective with other and Liver Cancer”, “Metabolic Syn- United Arab Emirates global health problems. drome – Hepatic Steatosis – Insulin The Emirates Gastroenterology & 2. During the 2012 annual Ameri- Resistance - Obesity may be attached Hepatology Conference (EGHC) can Association for the Study of Liver to Cirrhosis and HCC?”, “Impact of 2013 will devote two hours of the Diseases’s meeting November 9-13 the Images for Screening – Diagnosis EGHC 2013 scientific program to in Boston, a two hour symposium on and Treatment of HCC”, and “Utility cover HCC, during their annual HCC: Geographical Challenges, took of HCC Screening and Therapeutic meeting March 22-24 in Dubai. place. Alternatives.” For a full listing of events taking place, visit http://www.wgofounda- tion.org/wdhd-2013-events-calendar. WGO & WGOF News

21 WORLD GASTROENTEROLOGY NEWS APRIL 2013

5th Egyptian Hepatology and Gastroenterology Post Graduate Course; 14th Egyptian International Workshop on Therapeutic Endoscopy Hope Work Success

Ibrahim Mostafa, MD Professor of Gastroenterology and Hepatology Theodor Bilharz Researh Institute Cairo, Egypt

The Egyptian International Work- For the 10th Anniversary of the Japan, Lithuania, Nepal, Netherlands, shop on Therapeutic Endoscopy was workshop, the organizing committee Pakistan, Philippines, Romania, Rus- started in 1999 and is a three day live decided to be more specialized and to sian Federation, Switzerland, Turkey, endoscopy workshop, endorsed by organize two back-to-back events: a United Kingdom, and the USA, as the European Society of Gastroin- two-day Hepatology and Gastroen- well as Egyptian experts. testinal Endoscopy (ESGE) and the terology Post Graduate Course and a The main theme of thePost American Society for Gastrointestinal two-day Live Endoscopy Workshop. Graduate Course is improvement Endoscopy (ASGE). This program has These events are now attracting more of the educational level in the fields become one of the largest GI Endos- than 1,000 physicians, not only from of Hepatology and Gastroenterol- copy course gatherings in the Middle the region but worldwide. ogy for physicians in the Middle East East and Africa. The International The meeting promotes and supports and Africa. The hot topics were GIT, Educational Post Graduate Course clinical and scientific activity of young liver diseases and GIT endoscopy. is endorsed by the American College physicians, through the emerging stars The course consisted of four sessions of Gastroenterology (ACG) and is in award, and offers help and support to including 24 state of the art lectures. collaboration with the World Gastro- African physicians in the field of GI The 2012 event was accredited by enterology Organisation (WGO). and Endoscopy. The meeting delivers the European Accreditation Council high standard education and scientific for Continuous Medical Education programming and is an excellent place (EACCME) and was granted nine to learn about the latest advances in European CME credits. the fields of Gastroenterology, Hepa- Success of the Workshop on Ther- tology and Therapeutic Endoscopy. It has been held annually for the past 12 successive years in December. It is considered the main window to Africa and the Middle East as we have around 1,000 attendees (increasing every year), from more than 50 different countries, including all Arab and Professors Cihan Yurdaydin, Turkey, WGO African Countries, in addition to the Secretary General, Douglas LaBrecque, USA, Bahamas, Belgium, Canada, Croatia, Meeting attendees participate in hands-on WGO Foundation Member and WDHD 2013 Cyprus, Czech Republic, France, training stations during the Workshop on Chairman, and Ibrahim Mostafa, Egypt, Course Therapeutic Endoscopy. Director. Germany, Greece, India, Indonesia, 22 WORLD GASTROENTEROLOGY NEWS APRIL 2013

apeutic Endoscopy was generated from supporting partners, outstanding organizing companies, 670 enthusi- astic doctors from 32 countries, 12 international experts, and 30 Egyptian and Arabic experts. There were 200 keen trainees at 10 hands-on training stations including Diagnostic Colonoscopy, Gastroscopy, Endoscopic Hemostasis, Endoscopic Mucosal Resection, Endoscopic Pol- ypectomy, GIT Stenting and ERCP, and 40 sessions (60 hours) were A lecture during the December 2012 meeting in Cairo. performed in two days. Five state of the art lectures with We faced very hard times organizing 24 selected video cases were held, such an event in all surrounding cir- in addition to the 500 cases done in cumstances. However, the success that the previous workshops over the last I have seen this year would never be 12 years. This 2012 event was also possible without support. I would like accredited by the EACCME and was again to thank all for what you have granted 10 European CME credits. done for us to reach that success. I would like to convey that success would never have been possible without very hard work and team spirit. 23 WORLD GASTROENTEROLOGY NEWS APRIL 2013

WGO Membership Update

WGO National Member Society WGO National Member Societies – Information and Update Forms Dues are Payable at DDW 2013! Each year, WGO national member so- Did you know you can pay your cieties and regional affiliates are asked WGO national member society’s mem- to submit a current WGO National bership dues during Digestive Disease Member Society Information and Up- Week (DDW)? Just visit WGO at date Form. Each society has received booth 710 in Foundation Row at the a form via email, which may be up- Orange County Convention Center in dated and returned to membership@ Orlando, Florida, USA, during DDW The 2013 General Assembly will convene worldgastroenterology.org. If you 2013! The WGO booth will be open at Gastro 2013 APDW/WCOG Shanghai in need another copy of the form or have during the hours of 10:00 and 16:00, Shanghai, China. any questions about the information Sunday through Tuesday, 19-21 May. requested, please contact the WGO If you wish to pay your dues at DDW, Participation in the 2013 General Executive Secretariat at membership@ prior receipt of your society’s National Assembly worldgastroenterology.org. Invoices Member Society Information and As 2013 is a quadrennial World Con- are created based on the information Update Form by WGO will allow us gress year, with Gastro 2013 APDW/ received on these forms, and you will to have a current and correct invoice WCOG Shanghai taking place from receive your 2013 invoice promptly ready and waiting for you when you 21-24 September 2013 in Shanghai, upon receipt of the completed form. visit the booth! China, WGO national member soci- Your expedient response ensures eties are respectfully reminded that, Dues Payment Methods important WGO news and informa- in order to participate and vote in Membership dues may be paid by cash tion will be received promptly by the General Assembly meeting to be (in US dollars) or check, made payable the appropriate contacts within your convened in Shanghai in September, to the World Gastroenterology Organ- national member society, and your payment of membership dues must be isation. Please note, if you elect to pay cooperation is greatly appreciated! up-to-date. If you are unsure of your dues at the WGO booth, a receipt will society’s membership status, please be emailed to you as promptly as pos- contact the WGO Executive Secre- sible following payment. tariat at membership@worldgastroen- The dues that WGO national terology.org. member societies contribute each year are channeled into training, education Prospective Members and advocacy in the developing world, Are you interested in becoming a while also strengthening these aspects WGO national member society? Inter- in developed regions. WGO looks for- ested national societies are encouraged ward to receiving your society’s 2013 to apply. Please visit the membership dues and to keeping you, our national application section of the WGO web- member societies, apprised of all the site to learn more about the application current WGO and WGO Founda- process and required materials. tion news and events. Please watch WGO representatives in the WGO the monthly e-Alert and the quarterly booth during DDW 2013 will be e-WGN for the latest news! Visit us at the Orange County Convention Cen- more than happy to share with you ter during DDW 2013 in Orlando, Florida, USA! the benefits of WGO membership. 24 WORLD GASTROENTEROLOGY NEWS APRIL 2013

We invite you to stop by the booth, Promote your Society’s Event with Questions About Membership? speak with us, and read a wide variety WGO! To inquire on the status of your mem- of materials on the various WGO National member societies are encour- bership, or if you have any questions programs and initiatives which you aged to keep WGO informed of their regarding the information update or may take with you. If you have any meetings and events. To submit the dues payment processes, please con- questions about the membership details for your society’s upcoming tact the WGO Executive Secretariat at application process, please contact meetings and/or events for promo- membership@worldgastroenterology. membership@worldgastroenterology. tion on the WGO Online Confer- org. org and the Executive Secretariat will ence Calendar, please submit these answer any queries you may have! via the WGO website at http://www. worldgastroenterology.org/submit- event.html. 25 WORLD GASTROENTEROLOGY NEWS APRIL 2013

WGO Training Centers in Africa – A New Partnership in Training

As the global population steadily Ribeirão Preto and Porto Alegre, Bra- The Need for African Training increases, so too does the need for zil; in other parts of the world, WGO Centers access to healthcare close to home. To Training Centers are sited in Rome, Whilst WGO Training Centers are provide training for local and visiting Italy; Karachi, Pakistan; Bangkok, geographically dispersed, a grow- physicians from across the globe, the Thailand; and Suva, Fiji thus serving ing need has been identified in World Gastroenterology Organisation the needs of communities in and sur- sub-Saharan Africa. WGO seeks to (WGO) has established 15 Training rounding Europe, Asia, and the South expand its efforts in promoting and Centers located throughout the world, Pacific. The Training Centers in Sowe- advancing the practice of gastroen- the most recent addition being the to, South Africa; Rabat, Morocco; terology through the development of Porto Alegre Hepatology Training and Cairo, Egypt provide research and additional training initiatives within Center located in Porto Alegre, Brazil. training opportunities for gastrointes- Africa. These programmatic endeavors WGO Centers have served over 2,200 tinal-focused training and education have been made possible through a trainees and medical professionals of nurses, medical practitioners and five-year partnership with Karl Storz, since their inception. They offer -lo healthcare professionals within Africa who has generously agreed to provide cally relevant comprehensive train- and neighboring regions. Through an educational grant for the estab- ing in the fields of gastroenterology, Training Center programming, WGO lishment of three additional training hepatology, endoscopy, oncology and aims to optimize the standards of centers. These new centers, once GI surgery to further develop trainees’ patient care while ensuring a focus on established, will provide a series of skills and education. regionally-relevant digestive disorders; short and long-term courses, currently and reduce the “brain drain” of highly in development. These training initia- WGO Training Center Mission skilled practitioners from developing tives will expose trainees and health- The mission of the WGO Training countries by providing training and care professionals with opportunities Centers is to establish and nurture opportunities close to home. to enhance their skills and education core training centers for general and focused GI training in locations of need, thereby, improving the standard of training at a grassroots level while ensuring a focus on regionally-relevant diseases. With this in mind, WGO is embarking on a collaboration with Karl Storz GmbH & Co. KG who has committed to support the establishment of Training Centers in sub-Sa- haran Africa, where the need for such education and training is increasing. Training Center Locations Of the 15 WGO Training Centers eight are in Latin America: Mexico City, Mexico; Bogotá, Colombia; San Jose, Costa Rica; La Paz, Bolivia; Santiago, Chile; La Plata, Argentina; 26 WORLD GASTROENTEROLOGY NEWS APRIL 2013

not deemed possible due to lack of re- ment of the KARL STORZ group. equipment. WGO is grateful for the sources in their current environment. In 2013, KARL STORZ has about generous support of Karl Storz and 2,000 employees in its headquarters, looks forward to a continued partner- About Karl Storz and throughout the world 5,800 ship between the organizations to KARL STORZ GMBH & CO. KG is employees are engaged. grow the presence of WGO Training one of the world’s leading suppliers of On a world-wide level Centers in sub-Saharan Africa to ad- endoscopes, endoscopic instruments KARL STORZ is very involved and dress the growing need of training and and devices for more than 15 surgical dedicated to support medical training education close to home. disciplines in human medicine. The institutions with equipment so that Looking to the Future company designs, engineers, manu- young physicians can receive endo- As this endeavor progresses, we look factures and markets all its products scopic training in order that more forward to bringing you more infor- with an emphasis on visionary design, patients can benefit from the great ad- mation and updates as they become precision craftsmanship and clini- vantages of this surgical technique. In available. For more information on cal effectiveness. The family-owned this respect KARL STORZ strongly WGO Training Centers, please visit company was founded in 1945 by Dr. believes that medical education should http://www.worldgastroenterology. med. h. c. Karl Storz in Tuttlingen, remain in the hands of physicians. org/training-centers.html. Germany and in 1996, the daughter Therefore, KARL STORZ focuses on of the family founder, Dr. h. c. mult. supporting training institutions by Sybill Storz, took over the manage- providing logistics and high quality WGO Global Guidelines

27 WORLD GASTROENTEROLOGY NEWS APRIL 2013

WGO’s New Graded Evidence System AN INTERVIEW WITH DRS. JUSTUS KRABSHUIS, PUBLISHING EDITOR, WGO GRADED EVIDENCE SYSTEM

Justus Krabshuis Anton Le Mair, MD Highland Data WGO Guidelines Project Tourtoirac, France Amsterdam, Netherlands

Introduction as much as 2-3 years. WGO’s Graded published more than 400 papers in WGO’s ‘Grad- Evidence system bridges these gaps. gastroenterology and hepatology. ed Evidence’ The basis for GES is ‘raw data’ gen- Evidence Grading means assessing rel- System (GES) erated by very precise journal searches evant studies in terms of quality as well is built to help in Pubmed Medline for meta-analyses, as its relevance for the guideline topic members of systematic reviews, randomized in question. Articles are then scored by National Soci- controlled trials and practice guide- assigning one, two or three stars: eties of Gastroenterology and all those lines covering the topics of all WGO key development interested in the practice and research Guidelines.  of gastroenterology and hepatology WGO is honored to have been able  very important to enlist the expertise and assistance keep track of the literature in topics  important covered by WGO Guidelines. of Professor Andre Elewaut from WGO’s GES and WGO Guidelines Gent and Professor Johan Fevery from − special mention work together closely. The guidelines Leuven in the grading of evidence to For more than 15 years, publishing are regularly reviewed and updated and support our WGO practice guidelines. responsibility for GES has been in the built when new information becomes They have an impeccable science capable hands of Justus Krabshuis/ available. However, new evidence background – for example, together Highland Data. We asked Justus to appears constantly, and the ‘lag time’ they are past co-chairs of the UEGW tell us something about the old and for a guideline to be updated may be Scientific Committee. They are a for- the new Graded Evidence System. midable pair of Editors who, together,

Adding value from Belgium

Professor Andre Elewaut Professor Johan Fevery 28 WORLD GASTROENTEROLOGY NEWS APRIL 2013

What’s new? Pubmed on the other hand is ‘Open Q: Drs. Krabshuis, can you tell us Q: What is the difference between Access’ and all 20 journals are covered about the GES improvements and GES and other information services, by Medline. Through our WGO Ask why it has now changed? such as online search alerts, journal a Librarian service we can provide A: The time has come to put the subscriptions, and practice guide- more comprehensive evidence and service on a more professional footing. lines? that would also involve searching the Management of GES will be done by A: I think the key difference is that Cochrane library. WGO in-house – by EDI – the U.S.- GES is edited by two eminent gastro- based Association Management Com- enterologists. They scan and read and Q: So, is GES really evidence-based? pany that manages all WGO interests. evaluate top research published in top How can the user be sure to trust the I will, however, remain responsible journals and decide whether a new assigned GES levels? for the quarterly literature searches. A study is really ‘key’ and important. A: GES is most certainly evidence- significant improvement in the new Both editors have eminent scientific based. The update strategies are GES is that the editors now have a backgrounds. Most other alerting precise rather than comprehensive. separate ‘field’ for ‘comments’. So the services – like our own WGO Virtual Evidence levels are guided by the value they add is not only ‘selection of Room of Gastroenterology – see http:// CEBM. The assignment of a qual- articles’ and assignment of a qual- www.labovirtual.com.ar/vrg.htm – are ity score, however, involves expert ity code, but they will also provide based on bibliometric and/or search opinion. Evidence is a very difficult comments (if they wish); i.e. they can parameters without ever passing the attribute if you start to think about argue why a paper is important, not eye of a clinical expert. it. Evidence is a continuum and at just say it is important. the more principled end (some would Evidence & currency say fundamentally) no effort or cost Q: Which journals are now covered Q: You only search for level-1 evi- is spared to track down even the by GES and why? dence? Why is that? most elusive RCT – perhaps never A: It is easy to A: We want to help everyone be aware published. But when is there enough tell you which early of new evidence. We only track evidence? And could it be said that for journals are cov- Systematic Reviews, Meta-analyses the substantial resources required to ered. They are and Randomized Controlled trials. do a very comprehensive Systematic the top 10 Gas- Other Controlled Clinical trials, Review – taking perhaps a few years to troenterology cohort studies and case studies may do and major investment – instead we and Hepatology generate lower level evidence but we could do even as many as 100 rapid journals plus do not track this. WGO provides a scoping reviews? By doing 10 System- the top 10 general medical journals free ‘Ask a Librarian service’ which can atic Reviews you maybe condemned – based on the journal impact factor. provide ‘on-demand’ high and or low- to worse outcomes (on average) for It is not easy at all to justify this. We er level evidence. We normally follow zillions of patients. There are opportu- all know that evidence is not really the CEBM levels – Oxford Centre for nity costs to expending further effort, influenced by ‘where’ we find it. Or Evidence Based Medicine – see http:// and (especially as diminishing return is it? Is good research more likely to www.cebm.net/index.aspx?o=1025. of evidence found per effort sets in) be published in high impact factor at some point the increased precision journals? We would need to consider Q: Why do you not search the Co- will not be worth the extra cost. prestige and journal quality. To be chrane Library and other sources of Some of these ideas were suggested realistic – the graded evidence service high quality level-1 evidence? earlier this year by Jon Brassey (of will keep you up to date with key A: We search level-1 evidence in the TRIP database fame) on what is prob- developments. It will not give you a top 10 GI journals. The databases of ably one of the best and free listservers Cochrane-like comprehensive over- the Cochrane Library provide high for EBM methodology - evidence- view of everything published in the quality information – however, the [email protected]. area covered by our WGO Guidelines CENTRAL database with its com- – it may come close though! prehensive selection of RCTs and Q: How current is your system – See http://www.worldgastroenterology. the Systematic Reviews Database when an article appears in Pubmed, org/graded-evidence.html for the new are not available everywhere in the how long does it take before it is list of journals. world – although it is getting better. available on the GES? 29 WORLD GASTROENTEROLOGY NEWS APRIL 2013

A: It varies. Q: What are the main benefits of Q: What is the future of GES in view Our update GES to the user? of technical developments such as searches are A: GES helps gastroenterologists, Google search and mobile access to done quarterly endoscopists and hepatologists keep information? so at worst the up to date with key developments in A: I am not sure. Is there a future role evidence is their subject areas. At the same time for ‘Expert Assessment’? Can ‘experi- never more it provides an update service for all ence’ ever be ‘captured’ in evidenced than three months old – on average those who consult our online WGO based medicine? It certainly is the six weeks. However, Pubmed does Guidelines at http://www.worldgastro- orphan child in all definitions of not evaluate – everything is published enterology.org/global-guidelines.html. evidence-based medicine – going right without a score for quality. By con- back to David Sackett (and Gordon trast, our editors carefully select and Q: WGO is very aware of their Guyatt) at McMaster in Canada. This evaluate and so GES may well be the ‘global’ purpose, how does GES help was Sackett’s Evidence Based Practice first to recognize the importance of a healthcare workers in low resource (EBP) definition that most people particular study. regions? know by now – but it is worth repeat- A: It helps to have access to the latest ing I think: Q: The source of the evidence is im- high quality information – more and Evidence Based Practice is “the portant - can we easily have access to more CME conscientious, explicit and judicious use the full text of selected articles? (continu- of current best evidence in making deci- A: This is a problem area. The Editors ing medical sions about the care of the individual have long asked me to provide access information) patient. It means integrating individual to the full text of articles they consider is important to clinical expertise with the best available evidence and of key importance. improve patient external clinical evidence from system- However, none of the gastroenterol- care, also in atic research.” (Sackett D, 1996) ogy and hepatology journals in the developing As you can see, for current evidence top 10 are open access. The copyright countries. GES is produced by Gas- to be meaningful we need individual barrier prevents us from publishing troenterologists for Gastroenterolo- clinical expertise. This is what Andre the text ourselves and providing a link gists, with special attention for global Elewaut and Johan Fevery give us does not help as one hits a pay wall – issues. It provides the latest evidence, – it’s as valid today as it was when often $30 or even more per individual which forms an essential element of Sackett said it in 1996. article. Sometimes the WGO ‘Ask a CME. And by linking it to WGO’s Librarian service’ can help to provide Ask a Librarian service, colleagues in Concluding Note a copy of a key paper as published in low resource regions can sometimes Thank you very much Drs. Krabshuis the GES – we have wide networks and by-pass the pay walls of other services. for explaining what the new Graded authors are always willing to share a Evidence System is and what it can copy of their research. Q: Are there more GES services avail- provide to our WGO members and able by other information providers? Guideline users. I am very grateful for GES and WGO A: Almost all evidence-based alerting giving us a view in the GES ‘kitchen’ Q: Why is WGO providing GES and services – and there are quite a few and to hear more about your vision how was it started? – are commercial ventures. There are on the expert literature searches and A: We want to help colleagues – few that are free – one excellent free evidence finding process behind the especially in low and middle-income service is the TRIP database at http:// GES. A warm ‘thank you’ especially to countries. Professors Elewaut and www.tripdatabase.com/. This is a free the two expert editors from Belgium: Fevery have very kindly agreed to evidence-based high quality clinical Professors Elewaut and Fevery for put- work pro-bono and this has made it information service with a special ting in their time to make GES such possible for us to start. The Guidelines interest in Global health care – not a valuable information source for all project by the way was started by just Western views. Of course, there interested in the GI field. another famous Belgian – Professor are excellent commercial services like Guido Tytgat and not very long after MD Consult and UpToDate as well that we were lucky enough to ‘find’ as others, but the pay walls are often his fellow ‘Vlaming’ from Flanders. substantial. And so you could say this is all Evi- dence from Belgium. Calendar of Events

30 WORLD GASTROENTEROLOGY NEWS APRIL 2013

WGO Calendar of Events

The 48th International Liver ILCA 2013 Annual Conference United European Congress™ When: September 13-15, 2013 Gastroenterology Week When: April 24-28, 2013 Location: Washington, D.C., USA When: October 12-16, 2013 Location: Amsterdam RAI Convention Organizer: The International Liver Cancer Location: Berlin, Germany Center, Amsterdam Association (ILCA) Address: Messedamm 22 14055, Berlin Address: Europaplein, NL 1078 GZ, E-mail: [email protected] Organizer: United European Gastroenter- Amsterdam Website: http://www.ilca2013.org ology (UEG) PO Box 77777, NL 1070 MS Amsterdam E-mail: [email protected] Organizer: European Association for the Gastro 2013 APDW/WCOG Website: http://www.ueg.eu/week/ Study of the Liver (EASL) Shanghai Email: [email protected] When: September 21-24, 2013 Canadian Digestive Diseases Website: http://www.easl.eu/_the-interna- Location: Shanghai, China Week (CDDW) tional-liver-congress/general-information Address: Shanghai Expo Center, 1500 When: February 7–10, 2014 Shibo Avenue, Shanghai, China Location: Toronto, Ontario, Canada Digestive Disease Week (DDW) Organizers: Asian Pacific Digestive Week Address: 100 Front Street W Toronto ON 2013 Federation (APDWF), Chinese Societies M5J 1E3 When: May 18-21, 2013 of Digestive Diseases (CSDD), World Organizer: Canadian Association of Location: Orlando, Florida, USA Endoscopy Organization (WEO), World Gastroenterology Organizers: American Association for the Gastroenterology Organisation (WGO) E-mail: [email protected] Study of Liver Diseases (AASLD), Ameri- E-mail: congress_international@gas- Website: http://www.cag-acg.org can Gastroenterology Association (AGA), tro2013.org American Society for Gastrointestinal Website: http://www.gastro2013.org The 32nd World Congress of Endoscopy (ASGE), and The Society for Internal Medicine (WCIM 2014) Surgery of the Alimentary Tract (SSAT) Australian Gastroenterology Week When: October 26-30, 2014 Email: [email protected] 2013 Incorporating the Federation Location: COEX, World Trade Center Website: http://www.ddw.org of Gastrointestinal Societies Samseong-dong, Gangnam-gu, Seoul, When: October 7-9, 2013 Korea rd 23 Conference of the Asian Address: Melbourne Convention & Exhi- Organizer: The International Society of Pacific Association for the Study bition Centre Internal Medicine (ISIM) of the Liver (APASL) Location: Melbourne, Australia E-mail: [email protected] When: June 6-9, 2013 Organizer: Gastroenterological Society of Website: http://www.wcim2014.org Location: Singapore Australia (GESA) Organizer: The Asian Pacific Association E-mail: [email protected] Highlighted events represent WGO member for the Study of the Liver (APASL) Website: www.agw.org.au events. For a full listing of events, please visit E-mail: [email protected] http://www.worldgastroenterology.org/major- Website: http://www.apaslconference.org ACG 2013 Annual Scientific meetings.html Meeting and Postgraduate Course OESO 12th World Congress When: October 11-16, 2013 When: August 27-30, 2013 Location: San Diego, California, USA Location: Paris, France Address: San Diego Convention Center, Address: UNESCO, 125 Avenue de Suf- 111 West Harbor Drive, San Diego, fren, 75005 Paris California, USA Organizer: World Organization for Organizer: American College of Gastroen- Specialized Studies on Diseases of the terology (ACG) Esophagus (OESO) E-mail: [email protected] E-mail: [email protected] Website: http://www.gi.org Website: http://www.oeso.org